Patient Safety and Continuity of Care

ASHP Leadership Agenda Item

Promote pharmacists as the health care professional that is accountable for the medication-therapy outcomes of patients.

Background

Continuity of care is a complex, longitudinal process with direct implications on patient safety and well-being. Errors involving continuity of care account for approximately 13% of all sentinel events reported to The Joint Commission. To address this important patient safety issue, the 2007 National Patient Safety Goals encourages institutions to accurately and completely reconcile medications across the continuum of care. As medication experts, it is crucial for pharmacists to be involved in continuity of care-related initiatives in hospitals and health-systems.

To bring awareness to this important topic, SSHPs are encouraged to design and implement a project focusing on patient safety and continuity of care issues.

Objectives

• To demonstrate the vital role of health-system pharmacists and pharmacy students in patient safety and continuity of care issues;
• To encourage the use of a standardized personal medication record in all patient outreach projects;
• To increase awareness of patient safety and continuity of care issues; and
• To become familiar with the health-related and non-health-related issues which affect patients’ continuity of care.

SSHP Project Ideas

• Educate students and the public on the importance of establishing and maintaining an accurate personal medication record;
  Use the My Medicine List program or design and implement a “Brown Bag”-type program in the local community should include a review of medications currently used, assessment of possible drug interactions, assessment of possible therapeutic duplications, etc.
• Target educational efforts to specific groups or needs within the local community (elderly, disadvantaged, etc.);
• Invite local practitioners to participate in a panel or roundtable discussion regarding patient safety and continuity of care issues;
• Plan a “Chart Reading” workshop where practitioners and faculty are invited to help students learn how do disseminate pertinent medical history;
  Put together mock charts and invite other health care students to participate.
• Partner with local hospitals or health systems and/or state affiliates to participate in initiatives involving patient safety and continuity of care issues.

Resources

1. U.S. Food and Drug Administration My Medicine Record
2. Minnesota Alliance for Patient Safety (personal medication records in various languages)
3. The Joint Commission National Patient Safety Goals
4. ASHP Continuity of Care Task Force. Continuity of care in medication management: review of issues and considerations for pharmacy. Am J Health-Syst Pharm. 2005;62:1714-20.